CHAPTER CONTENTS

Definition of work-related musculoskeletal disorders

(WRMSD)
127
Risk factors associated with WRMSD
Multifactorial

128

128

Models for the pathogenesis of WRMSD

130

Repetitive movement
131
Definition
131
Repetitive movement biological responses and
pathology
131
Repetitive movement vulnerability of the hyperrnobile
Individual
131
Force
132
Definition
132
Force biological responses and pathology
132
Force: vulnerability of the hypermobile
Individual
132
Awkward posture
133
Definition
133
Awkward postures biological responses
and pathology
133
Awkward postures: vulnerability of
the hypermobile Individual
134
Static postures
134
Definition
134
Static postures biological responses
and pathology
134
Static postures vulnerability of the hvperrnobue
Individual
135
Whole body vibration (WBV)
135
Definition
135
Whole body vibration biological responses and
pathology
135
Whole body vibration vulnerability of the hvperrnobne
Individual
135
Cool temperatures
135
Cool temperatures biological responses and
pathology
135
Cool temperatures vulneraouuy of the hypermobile
Individual
136
Psychosocial Issues
136
Psychosocial issues biological responses and
pathology
136
Psychosocial issues vulnerability of the hvperrnobile
individual
136

Application of ergonomic principles to reduce

the risk of WRMSD in the hypermobile
individual
136
Ergonomics: the balance
137
Primary prevention
137
Surveillance identilymq vulnerable JOints
and tissue
137
Education and training awareness of risk factors and
recommended posture, work practices and manual
handling techniques
137
Ergonomic assessment and management
138
Secondary prevention
138
Job restrictions and task modifications
138
Education and training to prevent persistence or
recurrence of Injury
139
Ergonomic assessment and management
139
Tertiary prevention
139
Rehabilitation and gradual return to work/conditioning
139
Ergonomic assessment and management
140

Conclusion

140

9
Joint hypermobility and
work-related
musculoskeletal
disorders (WRMSD)
Jean Mangharam

Aims
1. To provide the reader with background
information about WRMSD, including the
definition, associated risk factors, proposed
pathogeneses, and the associated biological
responses and pathology
2. To explore the potential impact of having
hypermobile joints and lax tissue on the
development of WRMSD
3. To discuss pertinent ergonomic principles
and propose suitable applications.

DEFINITION OF WORK-RELATED
MUSCULOSKELETAL DISORDERS
(WRMSD)
The prevalence of musculoskeletal disorders
(primarily of the neck, upper limb and back)
among the workforce of European Union
Member States and the United States of America
is high and continues to be a major reason for
illness and financial burden in the workplace
(Violante et al. 2000, European Agency for Safety
and Health at Work (EASHW) 1999, Kumar 2001).
There is growing worldwide concern about the
prevalence of musculoskeletal disorders in the
workplace. International meetings and workshops such as the one carried out in April 1998 by
the World Health Organization in Sweden, and
several large-scale projects to investigate the problem, have been commissioned by national and
127

128

HYPERMOBILITY SYNDROME

international bodies. Three such investigations

and reviews include:
NIOSH (1997) The National Institute
for Occupational Safety and Health
(USA) carried out an extensive critical
review of epidemiological evidence for
work-related musculoskeletal disorders for
the neck, upper extremity and low back.
The review identified a number of specific
physical exposures strongly associated with
specific WRMSD, especially when exposures
were intense, prolonged, and particularly
when workers were exposed to several
risk factors.
European Agency for Safety and
Health at Work (EASHW) (1999) The
European Agency for Safety and Health at
Work requested the Robbens Institute,
University of Surrey, to describe and assess
findings of relevant research related to
work-related upper limb disorders (WRULD).
The review was detailed and systematic
in its presentation of the nature of the
problem, and proposed models of
pathogenesis, biological responses and
strategies for prevention.
National Research Council (1999)
The National Institutes of Health (NIH)
in the USA requested that the National
Academy of Sciences and National
Research Council convene a panel of experts
to carefully examine questions raised by
Congress concerning occupational
musculoskeletal disorders. Comprehensive
information related to tissue mechanics,
biological responses and proposed theories
about the interaction between workplace
extrinsic and individual intrinsic factors
were presented.
'Work-related musculoskeletal disorders' (WRMSD)
is an umbrella term used to describe musculoskeletal disorders which have been associated with
the work of the affected person. The term 'workrelated upper limb disorders' (WRULD) refers

particularly to work-related musculoskeletal disorders of the neck and upper limb. Several terms
have been used to describe WRULD, including
repetitive strain injury (RSI in Australia and
the UK), occupational overuse syndrome (OOS
in Australia), cumulative trauma disorders (CTD
in USA), occupational cervicobrachial disorder
(OCBD in Japan, Switzerland and Sweden),
tension headache and occupational disorder (in
Finland) and Occupational Complaint Number
2101 (in the former Federal Republic of Germany)
(Ireland 1995).
The term WRMSD does not suggest or imply
aetiology, nor specify a risk factor or anatomical
region affected. It suggests that the disorder is
musculoskeletal in nature and is related to the
occupation of those affected. The primary reason
for the controversy surrounding the terminology
and classification of WRMSD is its complex multifactorial aetiology, progression and prognosis
(NIOSH 1997, Mayer et al. 2000). The World
Health Organization clarified this by stating that
'Work-related diseases may be partially caused by
adverse working conditions. They may be aggravated, accelerated or exacerbated by workplace
exposures and they may impair working capacity.
Personal characteristics and other environmental
and sociocultural factors usually play a role as
risk factors in work-related diseases; which
may often be more common than occupational
disease' (WHO 1985, Identification and Control
of Work Related Diseases. Technical Report No.
174. General: World Health Organization, cited
in National Research Council and Institute of
Medicine 2001).

RISK FACTORS ASSOCIATED

WITHWRMSD

Multifactorial
NIOSH (1997) found that the epidemiological
studies investigating the role of physical factors,
work organizational and psychosocial factors in the

JOINT HYPERMOBILITY AND WORKRELATED MUSCULOSKELETAL DISORDERS

development of WRMSD for the neck, shoulder,

elbow, hand and back were not guided by an
established and consistent definition of WRMSD.
The presentation of WRMSD may have been based
on clinical pathology, the presence of symptoms,
objective pathological processes and/or work
disability (e.g. days away from work). Of the
studies reviewed, the most common health outcome was the occurrence of pain.
NIOSH (1997)and European Agency for Safety
and Health at Work (1999) have both stated that
the lack of standardized criteria for defining
WRMSD makes investigation and comparison
between studies difficult. NIOSH (1997) points
out that it would be useful to have a concise
pathophysiological definition and corresponding
objective clinical test for each WRMSD, to translate the degree of tissue damage or dysfunction
into an estimate of current or future disability and
prognosis. However, clinically defined WRMSD
often have no clearly delineated pathophysiological mechanisms for pathological processes.
Reviews of studies have shown that the physical risk factors that have been associated with
WRMSD include repetitive movement, forceful
movements, heavy physical work, awkward postures, static postures, contact stress (local mechanical pressure or high-impact external forces),
hand-tool vibration, whole body vibration and
cool temperatures (NIOSH 1997,European Agency
for Safety and Health at Work 1999, National
Research Council 1999).
NIOSH (1997) summarized the causal relationship between physical work factors and WRMSD
(Table 9.1). The studies reviewed displayed strong
evidence of a causal relationship between posture
as a risk factor on neck/shoulder disorders; a
combination of risk factors (repetition, force and
posture) on elbow disorders; a combination of
physical risk factors (repetition, force, posture and
vibration) on carpal tunnel syndrome; a combination of physical risk factors (repetition, force and
posture) on hand/wrist tendonitis, vibration on
hand-arm vibration syndrome; and lifting/ forceful movements and whole body vibration on

129

Table 9.1 Evidence for causal relationship between

physical work and WRMSD (NIOSH 1997)

Body part
Risk factor

Strong
Evidence
evidence

Insufficient
evidence

Evidence
of no effect

NeckandnecWshou~er

Repetition
Force
Posture
Vibration

V'
V'
V'
V'

Shoulder
Posture
Force
Repetition
Vibration
Elbow
Repetition
Force
Posture
Combination

V'
V'
V'
V'
V'
V'
V'
V'

Hand/wrist - carpal tunnel syndrome

Repetition
V'
Force
V'
Posture
Vibration
V'
Combination
V'
Hand/wrist - tendonitis
Repetition
Force
Posture
Combination
V'

V'

V'
V'
V'

Hand-arm vibration syndrome

Vibration
V'
Back
Lifting/
forceful
movements
Awkward
posture
Heavy
physical
work
Whole body
vibration
Static work
posture

V'
V'
V'
V'
V'

back disorders. There was insufficient evidence

of a causal relationship between vibration and
neck/shoulder disorders; force and vibration on
shoulder disorders; repetition and posture on
elbow disorders; posture on carpal tunnel syndrome; and static work postures on back disorders. It was pointed out that high-risk jobs would
typically be composed of tasks that expose the
worker to one or more risk factors.

130

HYPERMOBILITY SYNDROME

MODELS FOR THE PATHOGENESIS

OFWRMSD
Several conceptual models have been designed
to explain how multiple factors may interact to
increase the propensity of an individual to develop
a work-related musculoskeletal disorder.
A dose-response model for neck and upper
limb disorders was developed by researchers
from Denmark, Finland, Sweden, England and
the United States (Armstrong et al. 1993). The
model described four domains: exposure, dose,
capacity and response. These factors interact
within a model which considers the intrinsic and
extrinsic influencing factors. This model emphasizes the cumulative nature of work-related neck
and upper limb disorders.
A model developed by the National Research
Council (1999) shows how environmental work
factors and the individual's personal factors
can have an impact on the physiological pathways, progression and outcome of a WRMSD. The
model shows how individual factors and external factors, including external loads, organizational factors and social context, can have an

influence on the biomechanicalloading (internal

loading and physiological responses), internal
tolerances (mechanical strain and subsequent
fatigue) and outcomes (pain/ discomfort and subsequent impairment/ disability). Arrows between
the workplace factors and the person (Fig. 9.1)
indicate the various research disciplines (epidemiology, biomechanics, physiology etc.) that have
attempted to explain the relationship.
The model incorporates the role of various
factors associated with WRMSD, including work
procedures, equipment, environment, organizational factors, individual physical and psychological factors, non-work related activities and
social factors. The central physiological pathway
shows the biomechanical relationship between
load and the biological response of tissue. Loads
of various magnitudes can change the form of
tissues throughout the day (e.g. changes secondary to fatigue and work pattern or style). The
biomechanical loading can lead to symptomatic
and asymptomatic responses. If the load exceeds
a mechanical tolerance, tissue damage or reactions will occur. The feedback mechanisms (e.g.
pain) can influence the biomechanical loading

Figure 9.1 Conceptual framework of physiological pathways and factors that potentially contribute to musculoskeletal
disorders from National Research Council 1999. with permission from the National Academy of Sciences

JOINT HYPERMOBILITY AND WORK-RELATED MUSCULOSKELETAL DISORDERS

and load-response relationship. Adaptation may

increase the tolerance for greater biomechanical
loading, or allow tissues to sustain a greater load
until tissue tolerance is exceeded. The symptom
and adaptation outcome may subsequently interact with each other. Functional impairment may
result from the responses, symptoms and adaptations. Disability may ensue if the resultant
impairment is severe. Similarly, and sometimes
concurrently with physical loading, undesirable
organizational factors and the social context, if
sufficiently intense, can influence the way in
which the individual will respond and progress
with problems. Individual physical and psychological factors and non-work related activities
may also have an influence on the physiological
pathways.

Repetitive movement

131

Repetitive movement: biological

responses and pathology
It has been found that repeated loading of tendons,
especially if the load is tensile and in a transverse
direction (e.g. gripping, passing bony structures
or adjacent tissue, in awkward postures or end of
range), increases the risk of an injury (Armstrong
et al. 1984, Goldstein et al. 1987). The collagen
fibres may separate from one another following
repetitive activity, resulting in swelling and pain
(Chaffin and Andersen 1991). The swelling may
change the coefficient of friction between the
tendon and the sheath, leading to irritation of the
tissues as the tendon glides repetitively within its
sheath. A tendonitis or tenosynovitis may result.
Histological changes have been found following
tendon loading (Backman et al. 1990).

Definition

Repetitive movement: vulnerability of the

hypermobile individual

Repetitive movement usually refers to the execution of cyclical patterns of movement without
regular pauses or breaks between the cycles.
These cyclical movement patterns are usually
executed to complete subtasks within a task, and
a job would usually be composed of a variety of
tasks. The level of risk imposed by repetitive
movement will depend on the frequency of the
cycle, the force required during the movement,
the duration of the cyclical movement, the
frequency and duration of breaks within and
between subtasks, and the total cumulative exposure period. Often, the upper limbs, especially
the smaller joints (e.g. fingers and wrists), are
dynamic during repetitive movement, as these
tasks usually require high manual dexterity (e.g.
typing or playing a musical instrument). During
these tasks, central and core muscles contract
to stabilize the skeletal system while peripheral
musculature carries out repetitive contraction
and relaxation (e.g. keyboard interaction requires
repetitive finger flexion/ extension/ abduction/
adduction while the wrist, elbow, shoulder and
shoulder girdle remain static).

Joint hypermobility syndrome (JHS) patients

have been thought to be susceptible to tendonitis
of the upper and lower limbs. The explanation
may be that there is a variation in the properties
of their tendon collagen. Both deficiencies in
collagen production and deficiencies in collagen turnover have now been recognized in different variants of Ehlers-Danlos syndrome (EDS)
(Beighton et al. 1998, Miller and Gay 1987).
Garcia-Cruz et al. (1998) found defective connective tissue in familial articular hypermobility
syndrome. Biochemical (collagen types) and
morphological variations were found (general
disorganization of dermal components, showing
a loose collagen network characterized by thick
bundles).
Despite the above findings, Larsson et al. (1993)
suggests that hypermobility may be an asset to
musicians, who require repetitive movement of
their joints. Results showed that musculoskeletal
symptoms associated with practice and performance may be due to lack of hypermobility of some
joints involved in intensive repetitive movement.
Subjects who played instruments requiring much

132 HYPERMOBILITY SYNDROME

more repetitive motion had symptoms that

affected their joints less often if the joints involved
were hypermobile than if they were not. Larsson
et al. (1995) reinforced their findings in ind ustrial
workers, when they showed that the individual
with a hypermobile spine was less susceptible
to back pain, in jobs requiring changing body
postures.

Force
Definition
Force may be a risk factor in situations when
the force required to carry out a task (one-off
or cumulative) exceeds that which can be created
(active) or withstood (passive) by the individual's
musculoskeletal system. Excessive stress or strain
can result from a single forceful mechanical event
(e.g. lifting, catching), from an interaction with
the environment (e.g. a fall), or from accumulated
strain associated with loading of a structure.
Probably - and more commonly - excessive tissue
strain can be caused by a combination of a single
high-force event superimposed on weak structures secondary to a history of repetitive loading
(Ashton-Miller 1999). Force can be defined as
external or internal, imposed either externally as
a load, or internally created by a motor response
or passive tensile stretch of connective tissue.
Force: biological responses and pathology
Muscle injury The sarcomeres of muscles
may be damaged morphologically at focal points
secondary to mechanical disruption during
contraction-induced injuries. The inflammatory
response may further damage the muscle units.
Striated muscle appears to be at higher risk of
being damaged during activation and being forcibly stretched, rather than during the isometric
phase of muscular contraction. The stretch may
be self-initiated or secondary to external loading (Ashton-Miller 1999). Edwards (1988) hypothesized that eccentric contractions have a high
potential for muscle damage.

Passive tensile structures Collagen provides the tensile strength in dense regular connective tissue. Collagen is an extremely active
substance that is sensitive to loading history.
Fluctuating loading usually promotes collagen
turnover, whereas static loading may lead to collagen atrophy. The turnover in avascular structures
such as intervertebral discs takes much longer,
and the various types of collagen have different
turnover rates (Ashton-Miller 1999).
Joint surface

Radwin and Lavender (1999)

discussed the findings of bone response to internal tissue loading. Several authors have reported
that osteoarthritis in the hip and knees is more
prevalent in individuals employed in occupations that experience greater loading of the lower
extremity.
Intervertebral disc

Researchers have found

that prolapsed discs occur more frequently in
the forward flexed position (Adams and Hutton
1982). In flexion, the anterior portion undergoes
compression and the posterior portion of the
annulus fibrosis is under tensile stretch. The disc,
especially the vertebral endplate, is particularly
susceptible to repetitive loading and large compressive forces in the forward flexed position
(Radwin and Lavender 1999).

Force: vulnerability of the

hypermobile individual
For the hypermobile individual, it appears that
several structures may be vulnerable when
high forces are imposed. Muscle strain has not
particularly been presented as an issue for the
hypermobile individual. However, passive tensile structures, bone structures and joint surfaces
have been presented as being vulnerable for
the hypermobile individual when placed under
stress.
Magnusson et al. (2001) showed that the passive properties of the hamstring muscle tendon
unit of JHS patients are similar to those of controls. However, their results suggest that JHS

JOINT HYPERMOBILITY AND WORK-RELATED MUSCULOSKELETAL DISORDERS

patients have a greater subjective tolerance to

passive stretch, displaying greater maximal stretch
angle (stretch sensation without pain) and corresponding peak moment.
Nijs et al. (2000) found that spinal and femoral
bone densities (volumetric total and cortical
bone at the radius) were lower in hypermobile
individuals, after correction for body mass index.
Comparisons were made between 25 female (Caucasian) hyperrnobile individuals aged between 19
and 57 years, and a corresponding age-matched
reference population. In contrast, an earlier study
by Mishra et al. (1996) found that although 31% of
58 patients with joint hypermobility syndrome
had significant arthralgia, there was no significant
reduction in bone mineral density.
Proprioception is critical for the maintenance
of joint stability. Studies have demonstrated that
proprioception is less accurate in patients with
hypermobility syndrome (Hall et al. 1995). Pathways between proprioceptive inaccuracy, knee
osteoarthritis and related knee disorders have
been suggested (Sharma 1999, Sharma and Pai
1997).
The vertebral column is stabilized by intersegmental muscles (e.g. multifidus, rotares, interspinales and intertransversarii) (Oliver and
Middleditch, 2000). Whereas spinal stability
tends to occur at the segmental level, the more
superficial longitudinal muscles counterbalance
external loads and achieve movement more successfully. Proprioception at the segmental level
would therefore be especially beneficial to
reduce the risk of injury of the facet joints and
intervertebral discs. Because of proprioception
limitations, the hypermobile individual has been
thought to be at greater risk of spinal injury.
Howes and Isdale (1971) stated that the 'loose
back' syndrome is accepted as being more common than originally thought.
Despite findings from the above studies,
Larsson et al. (1995) showed that there were no
significant effects of tasks involving heavy lifting
on hyperrnobile versus non-hypermobile individuals. However, the number of industrial workers

133

whose primary tasks involved heavy lifting in

the study was limited (12 females and 24 males).
Beighton et al. (1999)pointed out that throughout the literature it is widely thought that premature osteoarthritis may be a direct consequence of
hypermobility. However, final proof may only
follow a large and perspective long-term study
(Beighton et al. 1998).

Awkward posture
Definition
Awkward posture, as a risk factor, usually refers
to working in a joint range that is not in neutral
and which is often not optimal for muscular force
generation. Awkward postures may result from
an individual engaging in poor or suboptimal
work practices and postures, or working with
poor tool design, furniture design, equipment
design and/ or physical man-machine interfaces.

Awkward postures: biological responses

and pathology
Awkward postures often require muscles to exert
a force in a range which is not optimal for force
generation (either in shortened or lengthened
position), potentially leading to strain. Awkward
postures may also place adverse forces on joint
surfaces which are not coupled with congruence,
or compressive and stretching forces on various components of the musculoskeletal system,
including muscles, discs, tendons, joint capsules,
ligaments, connective tissue and nerve tissue.
Should the awkward postures be repeated or sustained during static work, impairments of various
components of the musculoskeletal system and
their interaction may be affected. Lengths and the
extensibility of various components of the musculoskeletal system may be altered and movement impairment may result (Sahrmann 2002).
Hypertrophy or shortening of certain muscles
and atrophy and lengthening of others may in
the long term lead to a muscular imbalance,
especially if the postural muscles that provide
stability close to the joints are not adequately

134

HYPERMOBILITY SYNDROME

recruited regularly, for maintenance of neutral

posturing.
It has been shown that awkward posture of
a single joint (shoulder flexion alone) can lead to
increased discomfort, muscular fatigue (detected
by EMG changes) and reduced performance
(Straker et a1. 1997).

Awkward postures: vulnerability of the

hypermobile individual
It is expected that the hypermobile individual will

be especially vulnerable to working in awkward

postures for sustained periods. Such individuals
may be particularly vulnerable to muscular
imbalances, as the deep core muscles fail to stabilize joints owing to poor proprioception during
prolonged awkward static postures. Repetitive
awkward postures may not pose as great a risk
at the hypermobile joints, because of the greater
extensibility of these joints. Silverman et a1. (1975)
demonstrated that a clinically hypermobile individual has greater extensibility of the fifth right
metacarpophalangeal joint by displaying the joint
angle response to increasing loads. The load versus joint angle curves showed that less load was
required to extend the joint to similar angles as
in controls, and the hypermobile individual
showed greater extensibility of that joint. The
authors also showed that the extensibility of
joints is inversely correlated with age. However,
should damage occur, the alterations in collagen
turnover and defects in connective tissue, as seen
in Ehlers-Danlos syndrome (Miller and Gay
1987) may leave the individual at risk of experiencing greater musculoskeletal problems, especially with increased age.

Static postures
Definition
During prolonged static postures low-level muscular contraction is required to maintain the stability
of a body segment. It has been suggested that muscular fatigue, tissue compression and alteration

in tissue extensibility may result in and lead to

movement impairment and muscular imbalances.

Static postures: biological responses

and pathology
Sustained postural muscle activity may lead to
muscle fatigue. Research has shown that muscle
fatigue does affect proprioceptive acuity. Because
proprioception is known to be important for
motor control, it has been hypothesized that
alteration in inhibition can increase coactivation,
inefficient muscle use and the workload of the
muscle affected (Ashton-Miller 1999).
It has been suggested that at low-level contraction adjacent blood vessels and nerves are compressed for prolonged periods, limiting blood flow
and nerve conduction to the periphery (Grandjean
1982). Hagberg and Hagberg (1989) reported that
at 30 of shoulder abduction, the perfusion of the
supraspinatus muscle may decrease as the intramuscular pressure increases with static contraction
of the muscle. Decreased blood flow in the supraspinatus may cause degeneration of the tendon
and rotator cuff tendonitis.
Veiersted et a1. (1993) found that myalgia may
result at low prolonged contraction levels. Jonsson
(1982) hypothesized that myalgia was secondary
to ischaemia due to high static load, with resultant occlusion or impedance of circulation. Hagg
(1998, cited in EASHW 1999) hypothesized that
myalgia may be associated with a specific pattern
of muscle recruitment, where selected muscle
fibres and motor units become vulnerable. There
is evidence of variance between the characteristics of the fibres in those exposed to high repetitive and static workloads compared to those who
have not been exposed to these factors. The irregularities observed appear to be related to the fibre
mitochondria. Hagg (1998) suggests that mitochondrial disturbances in type 1 (recruited for static
load exertion) muscle fibres in the upper trapezius
muscle follow exposure to static and repetitive
workload. Hagg suggests that these types of muscle abnormalities may be a necessary but not
sufficient condition for pain perception.

JOINT HYPERMOBILITY AND WORK-RELATED MUSCULOSKELETAL DISORDERS

The physiological mechanism underlying

muscle fibre abnormalities in the upper trapezius
muscle following static loads and complaints of
myalgia are only partially understood (Hagg
1998). This is due partly to methodological difficulties in taking muscle fibre from human subjects.

Static postures: vulnerability of the

hypermobile individual
Larsson et al. (1993)found that the daily problems
caused by hypermobility in musicians were not
related to the total number of hypermobile joints
in a subject but rather to the use of certain joints
when playing particular instruments. The percentage of subjects with hypermobile knees
who reported symptoms was significantly higher
(P < 0.001) than the corresponding percentage
among the subjects without such hypermobility.
The proportion of subjects with hypermobility of
the spine who had symptoms involving the back
was significantly higher than the proportion of
those who did not have hypermobility. The
authors felt that hypermobility of the spine, and
to some extent of the knees, can be a liability during long periods of practice and performance in
the erect posture, as an overuse syndrome (i.e.
pain in muscles involved in support function)
may be presenting. Larsson et al. (1995) found
similar results when he analysed the effects of task
types on industrial workers. The authors found
that workers with hypermobility experienced
more back pain with sitting or standing jobs than
workers without hypermobility. The corresponding numbers with back pain for jobs with
changing postures were greater for those without
hypermobility. The authors once again concluded
that hypermobility is an asset if the work
requires changes of body posture, but a liability
for those requiring static joints.

135

a whole. The motion is usually measured in the

'x' (front to back), 'v' (side to side) and 'r' (up and
down) directions. Once the direction of vibration
is defined the frequency and amplitude must also
be specified. The exposure to whole body vibration usually takes place through a supporting
seat or platform, generally in transportation
vehicles (e.g. bus drivers, truck drivers).

Whole body vibration: biological

responses and pathology
Bovenzi (2000)states that studies show that there
is an excess risk of sciatic pain and lumbar disc
disorders, including herniated disc, in the WBVexposed occupational groups compared to control groups. Mechanical overload and excessive
muscular fatigue has been shown by biodynamic
and physiological experiments.
Physical changes and disc herniations have
been caused in motion segments by exposure to
cyclic and vibration loading. A vehicle driver is
thought to also be at further risk when unloading, owing to back muscles that have fatigued
following exposure to vibration (Pope et al. 2000).

Whole body vibration: vulnerability of

the hypermobile individual
There has been no study found which proposes
that the hypermobile individual is more susceptible to problems following exposure to whole
body vibration. However, because of the vulnerability of hypermobile individuals to collagen
damage and intervertebral disc dysfunction,
caution is recommended in exposure to WBV.

Cool temperatures

Whole body vibration (WaV)

Cool temperatures: biological responses

and pathology

Definition

Studies suggest that the physiological demands

on muscle and related tissue will be greater for a
given task in a cold environment (EASHW 1999).

Whole body vibration refers to mechanical energy

oscillations which are transferred to the body as

136

HYPERMOBILITY SYNDROME

Increased muscle activity may arise from direct

cooling of tissue or postural changes.

Cool temperatures: vulnerability of the

hypermobile individual
The hypermobile individual may be more susceptible to cooler environments. Joint hypermobility
and bilateral occlusion of the ulnar arteries presenting as Raynaud's phenomenon have been
written about (Haberhauer et al. 2000). Beighton
et al. (1999) pointed out that alterations in the
total volume and weaving of collagen may result
from external forces, and that collagen fibres may
suffer contractions when the temperature of their
surroundings is changed.

Psychosocial issues
Psychosocial issues: biological
responses and pathology
Poor job or work organization, particularly lack of
sufficient control of the work by the user, underutilization of skills, high-speed repetitive working
or social isolation have been linked with stress
in the workplace today. Increased specialization
may result in jobs that require repetitive movement and/ or static positioning. Such jobs are also
usually associated with low job control.
It has been shown that there is an inverse relationship between physical load and job control
(MacDonald et al. 2001). MacDonald et al. 2001
found that the correlation between physical and
psychosocial stressors was strongest in bluecollar production and low-status office workers,
supporting their hypothesis that covariation is
more pronounced in groups with greater task
specialization. The factors that were especially
strongly correlated were low decision latitude and
physical loading. Mental demands were usually
negative with physical loading. The relationships
were weaker in white-collar workers.
It has been shown that psychological stress
can increase muscular tension (Waersted and
Westgaard 1996, Melin and Lundberg 1997).

Psychosocial issues: vulnerability of the

hypermobile individual
It has been pointed out that psychosocial problems may be experienced secondary to pain
associated with joint hypermobility (Grahame
2000). Although no specific studies relate work
satisfaction and hypermobile individuals, it must
be borne in mind that the interaction between
unsatisfactory work situations and stresses experienced secondary to pain may leave the hypermobile individual more susceptible and potentiate
the risk of problems related to psychosocial issues.

APPLICATION OF ERGONOMIC
PRINCIPLES TO REDUCE THE RISK
OF WRMSD IN THE HVPERMOBILE
INDIVIDUAL
The word 'ergonomics' is Greek in origin and
means natural laws (nomo) of work (ergo). One of
the guiding principles of the science is creating a
balance between the demands of a task and the
capabilities of the individual performing that
task (Fig. 9.2).
When the demands of a task, whether physical
or mental, are greater than the capability of the
individual doing the work in a specific environment, stress (physical or psychological), and consequently strain and injury, may result.

Figure 9.2

A primary ergonomics principle: creating a

balance between job task demands and individual capabilities
in the work environment

JOINT HYPERMOBILITY AND WORKRELATED MUSCULOSKELETAL DISORDERS

For individuals who have limited physical

and psychological capabilities, or for tasks that
are highly demanding, the application of ergonomics is especially important. What must be
borne in mind is that the balance between
individual capability and the demand of the task
is also highly influenced by the environment
where this balance must take place. For the
hypermobile individual physical capacity may
be limited relative to certain risk factors of a
task, such as high force and static postures,
but increased for other factors of a task, such
as repetitive movement or extreme joint range
requirements.

Ergonomics: the balance

The identification of risks, especially in the
context of the essential functions of the job, is the
first step in minimizing the risks associated with
WRMSD. Once high-risk tasks are identified,
specific risk factors can be objectively quantified
using currently available tools.
Risk exposure may be reduced by:
Redesigning a job so that high-risk tasks are
eliminated and not required;
Redesigning the way in which a task is
carried out, so that there is less risk;
Providing or designing equipment, tools
and man-machine interfaces to make the
task easy to complete;
Training people or providing them with
guiding procedures.
For any organization or individual (including
the hypermobile), ergonomic principles may be
applied at all three levels of prevention: primary
(prevention of onset of injury is a priority),
secondary (the goal is to prevent disability and
restore function quickly) and tertiary (when
physical impairment may already be present, but
prevention against further injury or impairment
is required to reduce the injury-disability cycle)
(Khalil et al. 1999).

137

Primary prevention
Surveillance: identifying vulnerable joints
and tissue
The vulnerability of the hypermobile individual
relative to work-related risk factors will depend
on what the task and total job requirements are in
relation to the individual's grade of hypermobility,
past medical history and specificity, and/or the
location of hypermobile joints. The ergonomist's
awareness of the individual's past medical and
current history of hypermobility will provide
greater ability to compare and match the individual with the physical and psychological demands
of their job. Creating a match between the job and
the user is usually attempted by altering the job
requirements initially. If the task or environment
cannot be modified, guidance regarding the avoidance of high-risk tasks is indicated. For example,
a hypermobile individual with a history of lower
back pain may choose to work as a cashier. As
practitioners, we may expect that individual to
be especially vulnerable to prolonged sitting or
standing postures. Should they continue working
as a cashier without the ability to break away from
that position, it is recommended that they alter
their posture intermittently between sitting and
standing, at an appropriate frequency, to reduce
prolonged static positioning.
Currently there is no scientific evidence that
validates the use of preassignrnent medical examinations, job simulation tests or other screening
tests as a valid predictor of which employees are
likely to develop WRMSD (Hales and Bertsche,
1999). However, a case for the introduction of
simple hypermobility screening for those destined
to participate in pursuits with a high risk of injury
has been made (March and Silman 1993).

Education and training: awareness of risk

factors and recommended posture, work
practices and manual handling techniques
Understanding the potential problems of joint
hypermobility and high tissue laxity relative to
potential work-related risk factors is imperative

138

HYPERMOBILITY SYNDROME

for all parties involved in determining optimal

ergonomic settings for the hypermobile individual, including the ergonomist, the individual
themselves, and personnel who have an influence on selecting and designating tasks for them.
Issues and factors about which it would be
important to have an understanding include:
High-risk work-related factors, including
static postures, high loading (force or
repetition) on connective tissues, possibly
whole body vibration, possible cold
environments and possible high-risk
psychosocial factors;
Applying basic control methods to reduce the
total exposure duration, frequency and dose
of the risk factor should be part of the
training for the hypermobile individual;
Postural education for dynamic tasks
(e.g. lifting, pushing, pulling) and static tasks
(e.g. sitting, standing, holding tools,
interacting with work equipment);
The importance of early reporting of
symptoms and intervention;
Encouragement to attend specialist physical
training (under the guidance of their
clinician) to improve the recruitment of
core stability muscles, joint proprioception
and kinaesthesia (movement awareness)
may be of benefit;
Ensuring task cycle breaks to reduce postural
muscle fatigue.
Should the individual find that their threshold
for mental demand or stress is potentially affected
by chronic pain or disability, the psychological
demands of the task must be considered. Such
psychosocial factors as total workload, time constraints, lack of autonomy, lack of performance
feedback and control over their job must be considered and evaluated by the ergonomist.

Ergonomic assessment and management

The ergonomist is encouraged to work closely
with the individual and the employer to provide

a systematic subjective and objective assessment

of the individual's status and job requirements.
Analysis of the findings and synthesis of potential problems should follow, so that realistic recommendations to reduce the risk factors may be
put forward. Appendix 1 provides an example of
an ergonomic assessment form used for those
who require individual consultation and specific
recommendations. The reader will note that photographs are sometimes used to present the scenario
much more clearly. Those approving and implementing the recommendations usually find the
pictures particularly helpful.
Follow-up after implementation of the control measures is essential. It is also recommended
that all ergonomic interventions be trialled prior
to being accepted as the final solution.
Should permission be provided by the individual, it may be highly beneficial for the ergonomist
to liaise with their clinician (medical doctor or
physiotherapist) to obtain a greater understanding
of the individual's condition and provide feedback about the workplace findings. Hales and
Bertsche (1999) state that open lines of communication between employer, employee and the
healthcare provider are essential. Attending combined clinics may be particularly valuable for
all parties involved (e.g. combined upper limb
clinic at the University College London Hospitals,
Rheumatology Department, attended by patient,
rheumatologist, therapist and ergonomist).

Secondary prevention
Job restrictions and task modifications
Employees returning to the same job without
modification of the work environment are at risk
of recurrence (Hales and Bertsche 1999). The principles guiding the return to work include the type
of WRMSD, the severity of the condition and the
risk factor present on the job. Following injury or
presentation of problems, it is highly beneficial
for the ergonomist to work closely with the clinician, should permission be provided by the patient.
Understanding the pathology, tissue mechanics

JOINT HYPERMOBILITY AND WORKRELATED MUSCULOSKELETAL DISORDERS

and working diagnosis allows the ergonomist

to analyse the individual's task more specifically
and reduce those risk factors that may be related
to the condition presented. For example, a hypermobile individual may present with right shoulder
instability and scapulothoracic pain, especially
aggravated by computer use. Closer analysis of
their task may reveal that intensive mouse use
in a non-neutral shoulder position is evident. Initially, the individual may be encouraged to avoid
mouse - and possibly keyboard - use by carrying
out alternative dynamic tasks (e.g. writing and
filing). As the individual recovers from the acute
condition, recommendations such as the avoidance of intensive right upper limb mouse use (e.g.
substitution by keystrokes, or left-hand mouse
use), postural training at the workplace, trying
an alternative keyboard design (which does not
have a number pad attached to the right, which
would normally restrict mouse placement) and
trying an alternative mouse design (e.g. a touchpad mouse, which does not require static shoulder girdle contraction) may be suggested. The
workplace findings and recommendations may
also provide the clinician with further understanding about the pathogenesis of the individual's
condition, and ideas for therapy (e.g. utilizing
EMG biofeedback to train the individual to
recruit lower trapezius for improved shoulder
stability and muscle balance, or using proprioceptive neuromuscular therapy to regain normal
proprioception and kinaesthesia of the upper
quadrant).

Education and training to prevent

persistence or recurrence of injury
It is imperative that the hypermobile individual

understands what the potential work-related

factors that may have aggravated their musculoskeletal condition are, so that exposure to them
may be reduced or avoided altogether. The ergonomist who has a full understanding of the individual's condition may be the practitioner best placed
to provide this advice, as they may be most
familiar with the particular risk factors.

139

Ergonomic assessment and management

Ergonomic assessments following injury or the
presentation of symptoms (reactive ergonomics)
may reduce the scope of the assessment but
increase its detail, as high-priority factors to be
corrected are usually revealed more readily.
General prophylactic ergonomic risk assessments
tend to require the ergonomist to think in a broad
and proactive manner, considering all factors
that may pose as risks. Appendix 9.1 presents an
ergonomic assessment form which may be used
at all levels of prevention.

Tertiary prevention
Rehabilitation and gradual return to
work/conditioning
Scientists confirm that rehabilitation and ergonomics applied together considerably intensify
and advance both the progress of the rehabilitation process and the return to normal life (Nowak
1999).
Returning injured or disabled workers to the
workforce through accommodations and redesign
of the work environment and tasks is possible
only with sufficient information about the physical and cognitive requirements of the task (Mayer
et al. 2000). A detailed ergonomic assessment
would usually reveal the requirements and physical capacity of the individual. The latter may not
be easily obvious in the work setting, as psychosocial factors and fear of reinjury may prevent
the individual from working at their actual physical capability. Functional capacity examinations
(e.g. Key and Blankenship methods) may provide the ergonomist with subjective and objective
measures of the individual's capacity. However,
the application of the objective measures may
be limited, because for many the information has
been collected within a controlled, rather than a
natural work environment.
Providing the injured worker with a job with
modified tasks during rehabilitation or following
physical impairment will allow them to maintain

140

HYPERMOBILITY SYNDROME

their function and often promote positive perceptions about their capabilities. It is important
that the modified task be one that is required for
normal or improved function for the organization
(rather than created for the individual, without
particular benefit to the organization), so that the
individual may feel valued and functional on their
return to work. Clinicians must advise which tasks
should be avoided, at various progressive stages
of tissue healing or rehabilitation. Gradual increase
of endurance is important not only for improving
total muscular strength and power, but also for
adaptation to new and controlled patterns of
movement (demands of proprioception and
kinaesthesia). Regular attendance at a workplace
will often require social interaction, and may
reduce the risk of the individual falling into the
trap of perceiving themselves as having a permanent disability.

Ergonomic assessment and management

Striking a balance between physical limitations
and job requirements requires a detailed understanding and recognition of all elements on
either side of the balance. The ergonomic assessment must usually be carried out with high sensitivity, so that progression to return to work can
be accepted rather than rejected by the individual. Should the individual be unwilling to increase
their function, because of either fear of physical

reinjury or increased social interaction within the

workplace, then the ergonomist must recognize
this early on. With consent of the individual,
a multidisciplinary approach (possibly with
input from the medical doctor, physiotherapist,
occupational therapist, psychologist, vocational
rehabilitation specialist) with commitment by the
individual's employer may be required for these
situations. Maintaining objectivity during the
assessment and presenting realistic goals is
especially important.

CONCLUSION
The prevalence of musculoskeletal disorders in
the workplace is high. The causes are thought to be
multifactorial and include repetitive movement,
the force involved, awkward and static postures,
vibration, temperature and psychosocial issues.
It is important to have an appreciation of the biological responses and possible pathologies that
can result from these factors in order to manage
symptoms successfully. This is particularly relevant in the hypermobile individual, who is possibly more at risk because of their more vulnerable
tissues. The application of ergonomic principles
is essential to prevent the development of musculoskeletal problems and successfully manage
problems when they arise.

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APPENDIX 9.1

143

Appendix 9.1
INDIVIDUAL ERGONOMIC ASSESSMENT

Personal information
Date:

Ergonomic assessor:

Client name
Gender
Date of birth
Employer/company
Job title
Business unit/department
Manager/contact person
Work location
Relevant past medical history
(stated by client)

Subjective assessment (reported by client)

Work status: Full-time/Part-time/PermanentfTemporaryfTrainee
Restrictions: Full duty/restricted duty/awaiting to return to work
Length of working day:
Frequency and periods of breaks (scheduled and natural):
Scheduled breaks:
Natural breaks:

Job description and designated tasks

Task

Description (% keyboard, mouse, screen, telephone, writing

where applicable)

Current relevant presenting complaints:

144 HYPERMOBILITY SYNDROME

Mobility of client: Wheelchair /walking with aids/walking independently

If client ambulates, is there a limitation?

Objective assessment (assessor's findings)

Primary workstation layout
(PHOTOS OR SKETCH)

Primary tasks observed

Repetitive
movement
(high/
medium/
low)

Static
postures
(high/
medium/
low)

Awkward
postures
(high/
medium/
low)

Equipment measures (mm) (e.g. in office setting)

Equipment type and model if obvious:
Desk:
Chair:
Mouse:
Keyboard:
VDU:
Other equipment:
Seat-pan height:
Seat pan width

x depth:

Lumbar support height:

Back rest width

x length:

Desk height:
Desk thickness:
Keyboard height:
Screen size (diagonal length):
Top of screen height:
Screen depth from eye:

Extreme
forces
exerted
(high/
medium/
low)

Contact
stress
(high/
medium/
low)

Vibration
(high/
medium/
low)

APPENDIX 9.1

145

Anthropometric measures (mm)

Anthropometric measures
Height:
Weight:
R/L-handed:
Knee height (heel to popliteus/top):
Mid-thigh height:
Hip height (joint):
Lumbar lordosis height (seat pan to lordosis):
Hips width:
Thigh length in sitting (buttock to popliteus):
Elbow height (seat pan to elbow):
Torso length (buttock to shoulder height in sitting):
Sitting eye height (seat pan to eyes):
Funct. reach length:

Health and safety

Yes

No

Has a risk assessment been carried out at your workstation?

Have you received training related to health and safety?

Environmental conditions
Acceptable
to client
Lighting conditions
Observed general hygiene level
Observed slips, trips, falls, hazards
Current noise level
Current air quality
Current temperature

Problems identified
1.
2.
etc.
Recommendations

Not acceptable to client (briefly state

issue) - recommended to be assessed by
employer

146

HYPERMOBILITY SYNDROME

Equipment
Equipment recommendation
Rationale
Details of installation and training requirements
Suppliers
Access

Access recommendation
Rationale

Workstation layout
Workstation layout recommendation
Rationale
Recommended workstation layout
(SKETCH)

Training - postural re-education and work practice

Training recommendation
Rationale

Task redesign
Task redesign recommendation
Rationale
Agreed by client
Other comments

Assessor's signature:

Printed name (qualifications):

Date:

_
_

(Developed by Jean Mangharam for ErgoSense Ltd, 2000)